Emergency Information

DENTAL HISTORY

What are the main concerns that you would like orthodontics to address?

Your current dental health is: GoodFairPoor

Have you ever had a serious/difficult problem associated with any previous dental work?

YesNo

Do you require antibiotics before dental work?

YesNo

General Dentist:

City/Phone:

Most recent visit to above dentist:

Have your adenoids/tonsils been removed:

YesNo

Do you have any speech problems?

YesNo

Do you have missing/extra permanent teeth?

UnsureYesNo

Do you still have any wisdom teeth?

UnsureYesNo

Have you ever had an injury to your:

MouthTeethChin

Do you now/have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

YesNo

Do you have/have you ever had any of the following habits?

Lip sucking/biting

Nail biting

Speech problems

Tongue thrust

Mouth breathing

Clenching/grinding teeth

Thumb/finger sucking

Tongue/cheek biting

Are you allergic to any of the following?

Aspirin

Erythromycin

Penicillin

Codeine

Latex

Tetracycline

Dental anesthetics

Metal/plastics

Please list any other drugs/materials that you are allergic to:

UPDATES - OFFICE USE ONLY

I have verbally reviewed the medical/dental information above with the patient named herein.

Date:

Initials:

Date:

Initials:

Date:

Initials:

Date:

Initials:

MEDICAL HISTORY

Personal Physician:

Physician's phone:

Your current health is: GoodFairPoor

Are you currently under the care of a physican?

YesNo

Please explain:

Please list any prescription/over-the-counter drugs you are taking:

Do you smoke/Use tobacco of any formYesNo

Are you pregnant? YesNo

Week #

Have you ever had/experienced any of the following?

Aids/HIV+

Hepatitis

Allergies

High/Low blood pressure

Anemia/radiation treatment

Hives/skin rash

Artificial bones/joints/valves

Kidney problems

Asthma

Liver problem

Difficulty breathing

Lupus

Arthritis

Measles

Blood transfusion

Mitral valve prolapse

Cancer/chemotherapy

Mononucleosis

Chicken pox

Osteoporosis

Congenital heart defect

Psychiatric problems

Convulsions

Rheumatic fever

Diabetes

Scarlet fever

Drug/Alcohol abuse

Seizures fainting/epilepsy

Emphysema

Severe/frequent headaches

Fever blisters/herpes

Shingles

Handicaps/disabilities

Sickle cell anemia

Hearing impairment

Sinus problems

Heart attack/stroke

Tonsillitis

Heart murmur

Tuberculosis(TB)

Heart surgery/pacemaker

Ulcers/colitis

Hemophilia

Venereal disease

Please list any other serious medical condition(s) that you have had:

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I understand that, where appropriate, credit bureau reports may be obtained.